Provider Demographics
NPI:1730796046
Name:FELLENZ, ANGELA (BCBA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FELLENZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W2427 SNOWBERRY DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:371 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4563
Practice Address - Country:US
Practice Address - Phone:920-907-3967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0-20-11369106E00000X
WI1138-140103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0-20-11369OtherBACB CERTIFICATION #
1-23-67656OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD
WI1138-140OtherSTATE OF WISCONSIN DIRECT LICENSING DEPT. OF SAFETY AND PROFESSIONAL SERVICES